What We Know

The Contribution of Family Planning towards the Prevention of Vertical HIV Transmission in Uganda

Hladik, W., Stover, J., Esiru, G., et al. PLoS ONE (2009), (4)11: e7691.

The authors used data on fertility, HIV infection, family planning (FP) use, and mother-to-child-transmission (MTCT) of HIV to create projections on the pediatric HIV burden in Uganda. These mathematical estimates indicated that family planning use—by virtue of preventing pregnancies among women living with HIV—averted a greater proportion of pediatric HIV infections (19.7 percent) compared to antiretroviral therapy (ART) for preventing MTCT (8.1 percent). Furthermore, the study found that unwanted fertility is a significant contributor to pediatric HIV cases. These greater benefits of FP use would remain even if ART use reached 80 percent of HIV-positive pregnant women. The authors argued that FP should be integrated in  programs for prevention of mother-to-child transmission, HIV TS programs, and postnatal care for all women of reproductive age, regardless of HIV status.

Unmet Need for Family Planning, Contraceptive Failure, and Unintended Pregnancy among HIV-Infected and HIV-Uninfected Women in Zimbabwe

McCoy S.I., Buzdugan, R., Ralph, l.J., et al. PLOS ONE (August 2014), doi: 10.1371/journal.pone.0105320. eCollection 2014.

This study assessed pregnancy intentions and contraceptive use among HIV-positive and HIV-negative women with a recent pregnancy (9–18 months prior to interview). Nearly 9,000 eligible women were randomly sampled from diverse catchment areas of 157 health facilities in Zimbabwe that offer services for prevention of mother-to-child transmission. Participants were asked about HIV status, whether the birth was intended, and contraceptive use to determine the frequency of unintended and mistimed pregnancy; frequency of unintended pregnancy and serostatus; and association between unintended and mistimed pregnancy and serostatus. Analysis showed links between unintended pregnancy and unmet need for contraception and contraceptive failure in this setting. Of the 35 percent who reported that their pregnancies were unintended or mistimed, about half reported unmet need and the other half contraceptive use/failure. Overall, 12 percent reported that they were HIV-positive; these women were significantly more likely than HIV-negative women to report unintended pregnancy . There was no association between self-reported HIV status and contraceptive use or  non-use among women with unintended births. Both HIV-infected and HIV-uninfected women reported unintended pregnancies despite their intention to prevent or delay pregnancy. This underscores that women in Zimbabwe need greater access to contraceptive methods, including long-acting reversible contraception, to help them meet their pregnancy intentions. 

Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations

World Health Organization, United Nations Population Fund, International Planned Parenthood Federation,  Joint United Nations Programme on HIV/AIDS, and University of California San Francisco  (2009).

This report reviewed 58 studies (including peer-reviewed research and documents on promising practices) describing linkages between sexual and reproductive health (SRH) and HIV services. Overall, findings indicated that integrated services improve behavioral, health, and social outcomes. The results were disaggregated by type of clinic (antenatal, HIV treatment, family planning, primary health care, sexually transmitted infection), and factors that facilitate or impede integration were identified. The contributing authors provided recommendations for policymakers, program managers, and research evaluators to guide the implementation of integrated SRH and HIV service delivery.

Reproductive Intentions and Outcomes Among Women on Antiretroviral Therapy in Rural Uganda: A Prospective Cohort Study

Homsy, J., Bunnell, R., Moore, D., et al. PLoS ONE (2009) Vol. 4 No. 1, p. e4149.

In a cohort of rural Ugandan women receiving antiretroviral therapy (ART), sexual activity and incidence of pregnancy significantly increased during follow-up, yet more than 93 percent of the women repeatedly expressed not wanting or not planning to have more children. In addition, more than 86 percent of sexually active women not desiring children were not using any modern contraceptive method other than condoms after two years on ART. In conclusion, women on ART and their partners should be consistently counseled on the effects of ART in restoring fertility, and should regularly be offered free and comprehensive family planning services as part of their standard package of care.

Family Planning and HIV

Wilcher, R., Cates, W., & Gregson, S. (eds.). AIDS (2009), Vol. 23 Supplement 1, pp. S1-S130.

The article was the first of 14 in the AIDS 2009 supplement devoted to filling key gaps in the literature on family planning and women living with HIV. The authors provided an overview of the evidence and studies contained in the supplement, starting with a history of the programmatic relationship between family planning and HIV services. They explained that the two fields have supported integration of services for more than 15 years, but limited funding streams often made it challenging to fulfill this goal. New evidence and policy support to better integrate services has emerged, and has been followed by increased funding and programs. The supplement included articles devoted to behavioral, biomedical, and programmatic research. The authors expressed their hope that the supplement would further discussion, support, and actual implementation of joint family planning and HIV services.

Benefits and Costs of Expanding Access to Family Planning Programs to Women Living with HIV

Halperin, D. T., Stover, J.,& Reynolds, H. W. AIDS (2009), Vol. 23 Supplement 1, pp. S123-S130.

Preventing unwanted pregnancies averts mother-to-child transmission (MTCT) of HIV. This study, funded by the U.S. Agency for International Development (USAID), modeled the effects of providing contraception to all women of reproductive age (WRA) and the cost-effectiveness of this strategy in 14 countries with the highest HIV prevalence among WRA. It also modeled the aggregate effect for 139 countries worldwide. The annual cost per infant infection avoided by offering antiretroviral (ARV) drugs to all women living with HIV was estimated to be U.S.$543 for the 14 high-prevalence countries ($609 was the estimated cost worldwide), whereas the cost of a birth averted, if all women who wanted contraceptives received them, was $61 ($63 worldwide). The authors said that it is critical for high-prevalence countries to promote and offer family planning as a cost-effective means of preventing MTCT. This article was one of 14 in the AIDS supplement devoted to family planning and women living with HIV.

A Randomized Controlled Trial to Promote Long-term Contraceptive Use Among HIV Serodiscordant and Concordant Positive Couples in Zambia

Stephenson, R., Vwalika, B., Greenberg, L., et al. Journal of Women’s Health (2011), Vol. 20 No. 4, pp. 567-574.

This intervention aimed to increase use of modern family planning (FP) methods among HIV serodiscordant and seroconcordant couples in Zambia. Study data came from a cohort of 1,502 couples recruited through couples voluntary counseling and testing clinics and enrolled in a randomized controlled trial. The study had four arms. The "methods" group viewed one video on modern contraceptives. The "motivational" group viewed a second video that demonstrated positive future-planning behaviors such as will preparation and pregnancy prevention. The third group watched both. The control group watched a video on other healthy behaviors. After the groups watched the videos, counselors answered questions. Couples were invited to initiate, add, or change their modern contraceptive method free of charge. At baseline, only 21.5 percent of couples reported use of a modern FP method. After the intervention, 1,407 couples chose a new method or continued their current method. The most popular methods among new users were injectables and oral contraceptive pills (OCPs); among the 324 couples who were already using a method at enrollment, OCPs were the most chosen method post-intervention. It was also found that when couples switched from one method to another, they most likely switched from OCPs to Norplant and injectables. The study increased uptake of modern FP methods to high-risk couples.

Impact of Integrated Family Planning and HIV Care Services on Contraceptive Use and Pregnancy Outcomes: A Retrospective Cohort Study

Kosgei, R. J., Lubano, K. M., Shen, C., et al. Journal of Acquired Immune Deficiency Syndromes (2011), Vol. 58 No. 5, pp. e121-126.

The United States Agency for International Development-Academic Model Providing Access to Healthcare (AMPATH) Partnership in Kenya assessed a pilot program intended to increase HIV-positive women’s use of family planning (FP) methods. The study measured differences between routine care (RC) and an integrated family planning services (IFP) model to determine the effect of additional FP services in HIV care on use of modern contraceptive methods and pregnancy rates. The AMPATH site was in a hospital in Eldoret, Kenya, where more than 17,000 adult patients were receiving HIV care. In RC, two groups of patients totaling 2,578 received FP services, including condom counseling and availability as a means to reduce HIV transmission. In IFP, 1,453 patients received RC in addition to FP services. It was found that in the IFP group that the incidence of new condom use increased, as did use of new FP methods including condoms; and the incidence of new FP use excluding condoms decreased. There was no statistical difference in the number of new pregnancies in the IFP group. Findings on the attributable risk of the incidence rate per 100-person-years of IFP and RC followed similar trends. The study demonstrates that an IFP model can be successful in HIV care sites.

Report on a PEPFAR technical consultation on “Addressing Multiple and Concurrent Sexual Partnerships in Generalized HIV Epidemics,” Washington, DC (October 29-30, 2008)

Stash, S. & Roseman, D. AIDSTAR-One (2008)

The 54-page report summarizes a technical consultation on MCPs held in Washington, DC. The meeting convened researchers, government representatives and program implementers from several nations, including the U.S. and Southern Africa, to address four themes: 1) the relationship between MCP and HIV transmission; 2) core components of MCP programs; 3) engendering community support for MCP activities; and 4) measuring program outcomes. The consultation concluded with group work and discussion on next steps. The report includes appendices with additional resources and a list of participants.

Ten Myths and One Truth about Generalised HIV Epidemics

Shelton, J.D. The Lancet (2007), Vol. 370, Issue 9602, pp. 1809–1811.

The author of this commentary states that common misperceptions impede HIV prevention efforts. For example, he says, commercial sex workers are not the problem since formal sex work is uncommon in generalized epidemics. Nor are men the problem since there is a high proportion of discordant couples in which women, not men, are HIV positive. The author comments on other perceived myths related to HIV, such as those surrounding condoms, HIV testing, and youth. He concludes that concurrency is central to generalized epidemics and that behavioral interventions are effective.


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